Sight & Sound Program

Transcription

1 Sight & Sound Program APPLICATION Valid July 1, 2017 through June 30, 2018 LIONS Sight & Hearing Foundation of New Hampshire, Inc. Ver A 501(c)(3) Charitable Organization Page 1 / 13

2 LIONS Sight & Hearing Foundation of New Hampshire, Inc. Dear Applicant, Thank you for contacting Sight & Sound of the LIONS Sight & Hearing Foundation of New Hampshire, Inc. for your cataract surgery and/or hearing assistance. We exist to provide assistance to those with no other resources to help them see or hear the world around them. The LIONS Clubs of New Hampshire support the efforts of this endowment as do the participating healthcare providers located around the state. Their involvement is crucial to the success of this program and we truly appreciate their efforts in this process. If your need is restricted to eyeglasses, there is a separate application form. Eligibility to the Sight & Sound Program is based on the applicants lack of ability to fund these services on their own. If you have the ability to purchase hearing aids or eyeglasses or vision services through any of the following resources such as: a family member, checking or savings accounts, mutual funds, 401 (k) plans, IRA accounts, CDs (certificates of deposit), stocks, bonds, treasury bills, property or any other instrument of value, then these avenues should be pursued instead of making an application to this program. Sight & Sound reviews all resources in determining your level of assistance. Our goal is to help those who truly cannot help themselves. As such, the hearing aids, eyeglasses and vision care will be of a quality commensurate with the hopes of helping as many people as possible within the limits of the funding of the endowment and the support of the LIONS Clubs of the state of New Hampshire. This should be viewed as a program of last resort. The applicant will contact their nearest LIONS club to initiate the process this application. A processing fee of $50 from the applicant and $100 from the sponsoring Lions Club, should accompany this application when submitted to the sponsoring Lions Club. The sponsoring LIONS Club will then submit the application to the Lions Sight & Hearing Foundation for review and approval. Every application will be reviewed for eligibility and should the application fail to meet all of the eligibility requirements, the processing fee may not be returned. We make every effort to assist those who truly need assistance. Should you have any questions, please feel free to contact the Project Coordinator, PCC Jim Robinson, 15 Wildbrook Drive, Plaistow, NH 03865, , jimrbnsn15@comcast.net. Mail completed application to the sponsoring Lions Club. If unable to reach a Lions Club, mail to: PCC Jim Robinson, 15 Wildbrook Drive, Plaistow, NH Ver A 501(c)(3) Charitable Organization Page 2 / 13

3 INFORMATION TO CONSIDER BEFORE COMPLETING THE SIGHT & SOUND APPLICATION 1. Income Guidelines: All income figures are NET. Net means the amount you actually receive in your check(s) regardless of the source. You can qualify if you are earning less than these annual incomes: 2. HOUSEHOLD INCOME 1 person $23,760 2 $32,040 3 $40,320 4 $48, Application and Order Processing Fee: $150 ($100 paid by the sponsoring LIONS CLUB & $50 paid by applicant). 4. Residence: Applicant must be sponsored by a LIONS CLUB chartered/located within the State of New Hampshire. Applicant either must reside in NH or be in a neighboring town covered by a sponsoring NH Lions Club. 5. In determining eligibility, Sight & Sound Program considers the following: all available funds, assets, and hearing and/or vision loss. a. Household Size (Household is defined as those living together or dependent on each other). b. Net Monthly or Annual Income from all in the household who have income. Possible sources of income are: Social Security Child Support Welfare Work Pension Black Lung Payments and SSI Public Assistance TANF Wages Interest from Stocks, VA Premium Alimony Disability Old Age Pensions IRAs, 401(k)s c. Assets (include, but not restricted to) Checking Annuities Savings Stocks / Bonds Money Market IRA / 401(k) CDs Burial Accounts Accounts Reverse Mortgage Home Equity Line Property 6. Review Addendum A Page 13 for a list of practitioners that may be able to serve your need(s). LIONS Sight & Hearing Foundation of NH s Sight & Sound Program reserves the right to change eligibility criteria without prior written notice. Ver A 501(c)(3) Charitable Organization Page 3 / 13

4 HOW TO COMPLETE THE PROCESS 1. Review and understand the application completely. 2. Contact the LIONS club nearest your home. To find the LIONS club nearest your home, go to: and click the link to the website for the club. Call the President or Health Liaison of the LIONS club nearest your home. Ask them if they would sponsor your application. If no response from the LIONS club you contacted, call PCC Jim Robinson at to discuss your eligibility. 3. Find a vision or hearing health care provider in your area who works with the Sight & Sound Program. This application provides you a list of health care providers currently associated with the Sight & Sound program. If there is a health care provider you would like to work with and they not on the enrolled list of providers, feel free to refer them to the Sight & Hearing Foundation of New Hampshire, Inc. 4. Schedule an appointment with the health care provider. See Addendum A, Page 13 - List of Healthcare Practitioners. Have the health care provider complete page 10 of this application. Obtain a copy of your hearing/vision test results from the health care provider and include with this application. 5. Complete pages 5, 6, and 7. NOTE: the applicant's signature is required on page Complete page 11 and Page 12 - the HIPAA Authorization Form. Page 11 - The primary care provider must sign the top for cataract surgery OR hearing aids. Page 12 - The applicant must sign the HIPAA Authorization Form to complete application. 7. Collect and attach income information for all those in the household. 8. Collect and attach copies of current tax returns and bank statements. Tax return must be no older than one year - include all W2's and 1099's. Bank statements are needed for each account belonging to each individual in the household. the applicant must sign the bottom for A copy of each page of each statement is required including copies of checks associated with the bank statement. 9. Collect the other necessary support documentation as outlined on page Include a Money Order or Cashier's Check for the applicants portion of the processing fee: $50 Make payable to: LIONS Sight & Hearing Foundation of NH, Inc. Personal checks will not be accepted. 11. Please do not send original documents as they will NOT be returned. 12. Submit application, supporting documentation and payment to your sponsoring LIONS club. Submission can be to the President of the LIONS club or to the Health Care Liaison, in person or by mail. Mailing address of the LIONS club can be found at: LIONS club will complete the Request for Funding and send the complete application to the LIONS Sight & Hearing Foundation of New Hampshire, Inc. for review and consideration. Please allow several weeks for processing as the foundation Board of Directors meets once a month. Incomplete applications will be returned to the applicant. You will be notified through the LIONS club if additional information is required to complete the application process. LIONS Sight & Hearing Foundation of NH, Inc. Sight & Sound Program reserves the right to change criteria at any time without prior written notice. Ver A 501(c)(3) Charitable Organization Page 4 / 13

5 GENERAL INFORMATION (Please Print Clearly) PROJECT #: Date: (For use of S&H Foundation only) Applicant's Name: First Middle Last Date of Birth: Age: Social Security #: Male Female Marital Status: Married Single Divorced Widowed Separated Number in Household: (Household is defined as all those living together or dependent upon each other.) Current Address: Street: Apt or Unit # (if applicable): City: County: State: Zip Code: Previous Address: Street: Apt or Unit # (if applicable): City: County: State: Zip Code: # of years at this address: # of years at this address: Home Phone: Work Phone: Cell Phone: If applicant is a Minor, Parent/Guardian's Name(s): Person, if other than applicant, completing this form. If Minor, list Parent/Guardian's Information Name: Relationship to Applicant: Home Phone: Work Phone: Cell Phone: INCOME If applicant is a Minor, list Parent/Guardian's income information List all sources of income (salary, social security, alimony, child support, pension, stocks, bonds, etc.) for all in the household. Applicant: A. $ Month or Year (circle one) B. $ Month or Year (circle one) Spouse / Other: C. $ Month or Year (circle one) D. $ Month or Year (circle one) Ver A 501(c)(3) Charitable Organization Page 5 / 13

6 ADDITIONAL INFORMATION Applicant Name: MARK 1 BOX FOR EACH ITEM. Unanswered questions will delay the process. Do you currently have: YES NO Current Tax Return (filed within last year) If yes, provide copy with all W2's and 1099's. If NO, please explain. Checking Account If yes, provide all pages, 3 months current bank statements.. Savings Account If yes, provide all pages, 3 months current bank statements.. Credit Card(s) If yes, provide most recent statement(s). CD(s) If yes, provide most recent statement(s). Stocks / Bonds If yes, provide most recent statement(s).. Annuity If yes, provide most recent statement(. IRA / 401k If yes, provide most recent statement(s). Money Market Account(s) If yes, provide most recent statement(s).. Burial Account If yes, provide most recent statement(s). Do you live in subsidized housing? If yes, provide documentation approval notice & rent amount. If you own your home, how much are your property taxes? Send current statement. Are you a Medicaid recipient? If yes, what is card #: Spend down amount: Are you a TANF recipient? If yes, when does coverage end? How much: Permanently Disabled Senior Citizen (age 65 & older) If yes, what is Medicare card #: Income Assistance If yes, describe: Insurance Coverage If yes, describe: EMPLOYMENT INFORMATION Employment Status: Employed Other Retired Occupation: Name of Current Employer: Date Hired: Phone: Time employed: (Years / Months) Date Left: Name of Previous Employer: Date Hired: Phone: Time employed: (Years / Months) Date Left: Ver A 501(c)(3) Charitable Organization Page 6 / 13

7 HOUSEHOLD INFORMATION Household is defined as all those who live together or are dependent on each other. Number in Household: List names of individuals in household. Use additional paper if necessary. Name Relationship Age of Person Monthly Income HIOUSEHOLD EXPENSES MONTHLY Apartment Rent / Mortgage Payment: and/or Amount paid by Section 8: Heat & Electric: Fuel Assistance Received: Food Allowance Received: Recurring Medical Expenses: Vehicle Expenses: Other Expenses: RELEASE OF INFORMATION I, the undersigned applicant/patient, understand I must work within the guidelines of the Sight & Sound Program of the LIONS Sight & Hearing Foundation of NH, Inc. a charitable non-profit 501(c)(3) and I agree to act in a civil and courteous manner with all people who are working to provide me with this treatment at little to no cost depending on the individual case. I also have been advised and understand follow-up care is critical to my successful treatment & recovery. Failure to attend follow-up appointments with the practitioners will jeopardize my treatment & recovery. I submit to Sight & Sound concerning my annual income, family size, family resources, insurance, medical history and all financial information are subject to verification by the LIONS Sight & Hearing Foundation of New Hampshire, Inc. and/or their agents. This verification will be done by phone, letter, and/or credit check and I hereby authorize your requesting my credit report. I understand that if I knowingly omit or submit false information, I will be denied consideration for assistance at any point during the process. I hereby authorize any individual or organization to release to the Sight & Sound Program any information necessary to confirm statements made in this application. I agree to hold Sight & Sound Program, LIONS Sight & Hearing Foundation of NH, Inc. and any LIONS CLUB of NH harmless from any injury resulting from treatment paid by them or associated with this application. I also understand that there are no expressed or implied services other than an exam and/or hearing aids. Applicant Signature: Applicant Signature: PRINT Name: PRINT Name: Date: Date: (If applicant is a Minor, Parent / Guardian signature required) If signed by Power of Attorney, (POA), please send copy of POA. The laws of the state of New Hampshire shall govern the resulting transaction and any claim or dispute arising out of such transaction. Ver A 501(c)(3) Charitable Organization Page 7 / 13

8 ADDITIONAL NOTES OR INFORMATION Use this space to provide additional information, if necessary. Ver A 501(c)(3) Charitable Organization Page 8 / 13

9 LIONS Sight & Hearing Foundation of New Hampshire, Inc. Dear Hearing or Vision Health Care Provider: Sight & Sound, a program of the LIONS Sight & Hearing Foundation of New Hampshire, Inc. is committed to helping low income individuals who reside in the state of New Hampshire and lack the resources to obtain needed vision care, and/or hearing aids. This program could not exist without the participation and enthusiasm of like-minded practitioners such as you. The commitment you show toward your community is a direct reflection of your practice. The LIONS Clubs of New Hampshire and the LIONS Sight & Hearing Foundation of NH, Inc. are equally committed to the many citizens of our state wide community in need of your services and our support. As you review the needs of the client in front of you, please take the time to provide us with as much information as possible regarding the clients vision or hearing condition and your recommendation for mitigating this condition to whatever extent possible under the guidelines of the Sight & Sound Program. An applicant's file is not complete without a written recommendation for care as provided by you, the practitioner. This written quotation should include, but is not limited to the following information: Original cost of hearing aid(s) and/or eye surgery Cost of ear mold(s), if any Batteries Insurance for loss and/or damage Discount cost of hearing aid(s), ear molds, eye surgery, etc. Professional fees (evaluation, fitting/dispensing, follow-up, etc. Repair Warranty - per year Other items specific to this clients needs The quotation must be submitted on your official letterhead and should include the name of a contact person who is familiar with the applicant's case. Please note we are unable to accept applications for service or devices which have already been fitted. The entire process of review, approval, and disbursement depends upon the completeness of appropriate paperwork and the availability of funds for disbursement. The Client Data Sheet (CDS) must accompany your recommendation of service. Thank you in advance for your cooperation in submitting the necessary information for the cost quotation. Applications are processed as quickly as possible so that, to the fullest extent possible, no person in need will go without assistance. LIONS Sight & Hearing Foundation of NH, Inc.'s Sight & Sound Program reserves the right to change eligibility criteria at any time without written notice. Ver A 501(c)(3) Charitable Organization Page 9 / 13

10 CLIENT DATA SHEET MEDICAL / AUDIOLOGICAL / VISION INFORMATION To be completed by the provider of the service. Name of Client: Date of Birth: Is this a fitting for: Hearing Aid(s) Cataract Surgery Is the client currently aided? Yes No Is the client currently using eyeglasses? Yes No Number of hearing aids requested: If fitting only one (1) ear, which ear are you fitting? Left Right When was the date of the client's last Hearing Test? Date of last Eye Exam? What is your recommendation to improve the client's hearing condition? What is your recommendation to improve the client's vision condition? PLEASE COMPLETE THIS SECTION FOR EACH CLIENT. THANK YOU Client's Account#: Name of Practitioner: Name of Practice: Address: City: State: Zip: Office Phone: Office Fax: State Licensure / Registration#: ASHA #: F-AAA #: IHS #: BC-HIS #: I do not have my CCC-A. Supervised by: State#: Signature: Date: address: Ver A 501(c)(3) Charitable Organization Page 10 / 13

11 Either Section A or Section B MUST be signed to complete this application. A MEDICAL CLEARANCE FOR HEARING AID USE and/or VISION CORRECTION To be signed by the client's Primary Physician Patient Name (please print): The patient listed above has been medically examined and may be considered a candidate for: Hearing Aid Use Vision Correction Physician Name (please print): Physician Signature: Date: B WAIVER OF MEDICAL CLEARANCE FOR HEARING AID USE ONLY To be completed and signed by the client Client Name (please print): I understand that it is in my best interest and recommended by Sight & Sound and the Food and Drug Administration to receive a medical examination before acquisition of hearing aids. I choose not to receive a medical examination before acquiring hearing aids. Client Signature: Date: Ver A 501(c)(3) Charitable Organization Page 11 / 13

12 AUTHORIZATION TO USE AND DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION IN APPLICATION & TREATMENT Application records that identify you will be kept confidential as required by law. Under federal privacy regulations, you have the right to determine who has access to your personal health information (called PHI ) which provides safeguards for privacy, security and authorized access. PHI collected in this application may include your medical history, results of physicals exams, lab tests, x-ray exams, other diagnostics and treatment procedures, as well as basic demographic information. The following individuals will or may have access to identifiable information related to your participation in this treatment process. Representatives from the sponsoring LIONS Club may review your PHI for the purpose of determining and making application for financial assistance. Reviewers will also include representative(s) of the Sight & Sound Program, the LIONS Sight & Hearing Foundation of New Hampshire, Inc. and healthcare practitioners for the purpose of monitoring the accuracy of the application, treatment and follow-up process. LIONS Sight & Hearing Foundation of New Hampshire, Inc. may review your PHI as part of its responsibility to ensure the funding process is implemented as directed by the Board of Directors of the LIONS Sight & Hearing Foundation of New Hampshire, Inc. Your PHI will not be used or disclosed to any other person or entity, except as required by law, or for authorized oversight of this application & treatment process. Please be aware that once PHI is disclosed, there is the possibility that your personal health information may no longer be protected by applicable privacy laws and regulations. The application and treatment information will be retained in your research record for a minimum of six years or until such time as further treatment is not required, whichever is longer. At that time either the application information not already in your medical record will be destroyed or information identifying you will be removed. Any application or treatment information obtained in your medical record may be kept indefinitely. This authorization does not expire. At anytime, you may cancel this authorization in writing by contacting the principal administrator listed on the first page of the application form. If you decline to provide this authorization, you will not be able to participate in the funding of this treatment. If you cancel the authorization, then you will be withdrawn from the treatment process. However, information gathered before the cancellation date may be used if necessary in completing the treatment or any follow-up for this treatment. In accordance with the USA Health System Privacy Notice document, you are permitted to obtain access to your PHI collected or used in this application or treatment. Such access will be granted upon written request submitted to the Project Coordinator of the Sight & Sound Program. I, have read and understand the HIPAA information provided. I agree to make any and all information provided available to the Sight & Sound Program, LIONS Sight & Hearing Foundation of New Hampshire, Inc., sponsoring LIONS Club and those practitioners involved in the diagnosis, treatment and financial assistance as initiated by the making and submission of this application. Signature of Applicant Date Ver A 501(c)(3) Charitable Organization Page 12 / 13

13 Addendum A Hearing Practitioners Contact list Call to make appointment must be Sight & Sound Program applicant to make Aria Hearing LLC Contact:: Mrs. Chris Gulick, HIS 27 Bank Street, Lebanon, NH (603) Main Street, Littleton, NH (603) Audio D & Finetone Contact: Dr. Ted Gauthier Office Mgr: Dr. Ted Gauthier 885 Roosevelt Trail, (Rte 302) Windham, ME (207) Office Mgr: Dr. Ted Gauthier 152 Rte 1, Suite #14, Scarborough, ME (behind Lois Market) (800) Dr. Woods Hearing Center Contact: Dr. Jessica L. Woods Office Mgr: Cameron Mills 17 Riverside Street Suite 104, Nashua, NH (603) Hearing Aid Shop Contact: Dr. Jessica Williams Office Mgr: Jessica Williams 22 Glendon Street, Wolfeboro, NH (603) White Mountain Highway, North Conway, NH Hearing Enhancement Centers Contact: Al Langley & Latoya Beck Office Mgr: Latoya Beck 173 South River Road, Bedford, NH (603) Office Mgr: Latoya Beck 6 Loudon Road, Concord, NH (603) Office Mgr: Latoya Beck 36 Country Club Road, Gilford, NH (603) Office Mgr: Latoya Beck 20 Glen Road, Gorham, NH (800) Office Mgr: Latoya Beck 1 Wakefield Street, Rochester, NH (603) New Hampshire Hearing and Balance Contact: Dr. Sally Fodero Office Mgr: Mark Fodero, HIS 655 Portsmouth Avenue, Greenland, NH (603) Northeast ENT & Allergy, P.C. Contact: Dr. Beth Cavalieri Office Mgr: Dr. Beth Cavalieri 158 State Route 108, Suite B, Dover, NH (603) renew Hearing Contact: Dr. Laurie Barnes Office Mgr: Anne 750 Lafayette Road, Suite 2, Portsmouth, NH (603) Vision Practitioners Contact List Call to make appointment must be Sight & Sound Program applicant to make Laconia Eye & Laser Center Contact: Dr. Andrew Garfinkle, Dr. Douglas Scott Office: Toni Fusaro, CMPE, Admin 368 Hounsell Ave, Gilford, NH (603) Tenney Mountain Highway, Plymouth, NH (603) NH Eye Associates Contact: Dr. David Corbit, Dr. Kimberly Licciardi Office: Jen Griffin x Elm Street, Manchester, NH (603) Buttrick Road, Bldg C, Unit 3, Londonderry NH The Eye Center of Concord Contact: Dr. Maxwell Snead Office: Stacy Ballard - Billing 2 Pillsbury Street, Concord, NH (603) Office: Genevieve Hartwick - Surgical Coordinator Ver A 501(c)(3) Charitable Organization Page 13 / 13